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SYMPTOMS OF NASAL DISEASE                         17

Migraine, which is frequently ushered in by an ocular prodromal symptom
and is associated with nausea, causes a unilateral headache due to the
vasomotor disturbance of the meningeal arteries. It is of variable duration and
frequency, and is controlled by ergot.

'Cluster headache*, or histamine headache, facial migraine, or spheno-
palatine neuralgia, is of vascular origin, being due to episodic dilatation of
facial vessels. It occurs in young males in whom it causes intense unilateral
headache around one eye and sometimes extends towards the temporal
region. These attacks come on during the night, and during the attack the
ipsilateral side of the face is flushed. The pain often ceases with the outpouring
of a watery rhinorrhoea from the same side of the nose. These attacks are
controlled by ergotamine tartrate (Femergin), either by injection (0-5 mg) or
orally given up to 5 mg daily; or by methysergide (Deseril) given 4-6 mg
daily in divided doses. Clonidine (Dixarit) is said to diminish the response of
the cranial vessels to constriction or dilatation, and may be given over a
period in doses of 25 fig twice daily.

Temporal arteritis9 which is due to a granulomatous arteritis of the vertebral
or cerebral arteries, leading ultimately to their occlusion, gives rise to pain in
the scalp, face and jaws. The pain is constant and is aggravated by chewing.
This is a self-limiting disease of the elderly which may end in blindness in half
of the sufferers. It should be treated by prednisolone in doses of 40-60 mg

Jrigeminal neuralgia is the most severe of the neuralgic pains, and causes
intense spasms of pain in any or all branches of the fifth nerve. Many of these
patients have trigger points around the nostril or on the upper lip, palpation of
which—as in the acts of shaving or washing—initiates the spasm. The aetiology
is unknown. There may be remissions between the attacks. It is treated by
carbamazepine (Tegretol) in doses of 100 mg once or twice daily, increasing the
dose until relief is obtained. This drug is so specific in its action that the
operations of alcohol injections into the ganglion or nerve, or root section of
the nerve, are now less frequently indicated. Glossopharyngeal neuralgia is
discussed on p. 114.

Anterior ethmoidal neuralgia is due to pressure on the anterior ethmoidal
nerve in the region of the anterior end of the middle concha and the adjacent
part of the nasal septum. It causes periodic pain from the eyebrow down the
nasal bone. The pain is not intense, but may make the wearing of spectacles
uncomfortable. Inspection of the nose will show a high deflection of the
septum pressing on the middle concha, and the treatment is a submucous
resection of the nasal septum and a fracturing of the middle concha medially.

Atypical facial neuralgia is a generic term to include many complaints of a
deep dull ache in the maxillary region in one side or both, and which is not
confined to any nerve distribution. It is more commonly found hi somewhat
haggard middle-aged women, and before labelling them neurotic one must
exclude any cause in the sinuses or teeth. There is no specific treatment if these
investigations are negative. Many of the patients have had their teeth removed,
and even nerve sections performed, in an effort to get relief. Most will require
a neurological investigation, and, if this is also negative, a psychiatric opinion.

Temporomandibular pain may arise from malfunction of the temporo-
mandibular joint. The pain is often acute and may be facial or referred to the
ear, and if aural examination is unrewarding the oral surgeon may detect an